Healthcare Provider Details

I. General information

NPI: 1730334079
Provider Name (Legal Business Name): RICHARD GEORGE PETTY M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/01/2008
Last Update Date: 12/01/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2430 TUCKER DR BLDG A
LOGANVILLE GA
30052-4390
US

IV. Provider business mailing address

2430 TUCKER DR BLDG A
LOGANVILLE GA
30052-4390
US

V. Phone/Fax

Practice location:
  • Phone: 770-554-8812
  • Fax:
Mailing address:
  • Phone: 770-554-8812
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code171100000X
TaxonomyAcupuncturist
License NumberAK000401L
License Number StatePA
# 2
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License NumberMD052287L
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: